North Dakota: The Decline of Rural Healthcare

In the past several decades, the population of rural America – particularly the Midwest – has seen a drastic decrease. This plummet in rural citizens has led to schools closing and local businesses failing due to lack of students, employees, and customers. Despite this steady decline of rural Midwest residents, the average age of the populace continues to increase; consequently, so has the percentage of residents that require frequent medical care. There are few healthcare providers to care for this aging rural population in the United States.

A number of changes contribute to the decrease in the population of rural America; one is the advancement of agricultural technologies. These technologies include machines that are larger and more productive than their predecessors, allowing farmers to manage more land than in the past. For instance, the average acreage of US farms increased from 589 acres in 1982 to 1,105 acres in 2007.1 For Midwestern farms, however, this figure is a conservative estimate. Some states like California and Virginia have seen the average farm grow less than 50% since 1982.1 During the same period, all 12 Midwestern states witnessed the average farm size increase by more than 100%.1 Since these states are experiencing the most rapid expansion of farms, they are also experiencing the largest decrease in rural population.

Notably, improvements in agriculture technology in the rural United States are not the only contributor to the rural population slump. Although rural, scenic regions like the Rocky Mountains and southern Appalachia have recently experienced an increase in residents because of migrating retirees, the rural Midwest’s population continues to decline because fewer people, both young and old, desire to move there.5 A recent Harris Poll asked people of various demographics in which states they would most want to live; of the top fifteen states, not one was in the Midwest.3 However, the Midwest shone brightly on the list of bottom fifteen states. One-third of the states listed on the bottom—including Illinois, Michigan, North Dakota, Kansas, and Missouri—were Midwest states. Since these areas are not desirable to the majority of people, rural areas continue to decrease in population while urban populations soar.

As rural populations decline, so does the quality and availability of healthcare for the remaining occupants; Ursula and Boyd Shaw experience the deleterious effects of this phenomenon. Fifty years ago, when they were in their early twenties, Ursula and Boyd moved to Parshall, a town of 1,000 people in rural North Dakota. During the school year, Ursula operated a day-care service and Boyd taught at the town’s only high school. When summer rolled around, they grew crops on their newly purchased family farm. When they first moved to Parshall, there were two clinics, two pharmacies, a dentist, a nursing home, and many other thriving businesses. During their final years there, however, Parshall hardly resembled the town it once was. Most of the businesses had closed because they lacked customers. For healthcare, the only remaining providers were a dentist open twelve hours a week and a pharmacy technician who filled prescriptions through telepharmacy (video calling a pharmacist so technicians can legally fulfill prescriptions). When asked why Parshall was no longer the boisterous town it once was, Ursula said, “The farms got bigger. Before, you had a farmer on every quarter of land. And now, for a mile, you might not find a farmer. Businesses couldn’t stay.”

Boyd and Ursula Shaw in their new home. Source: Myles Odermann.

Businesses were not the only ones who could not stay. Last year, Ursula and Boyd had to leave their home for the same reason as many other rural elderly: Healthcare in Parshall was insufficient. After the local clinic closed in 2013, Parshall could no longer provide resources for their basic medical needs, so they had to travel one hour each way to the nearest city, Minot, for healthcare. Between therapy, dentistry, and primary care, the Shaws traveled to Minot every week; eventually, it became implausible to live in Parshall. So after living for nearly a half-century in a community they loved, Ursula and Boyd saw no other option than to move to a city that could provide care for their basic health needs. “I thought I was going to die in Parshall,” Ursula said as she hid her displeasure with a forced laugh; “I’d still be there. We’d still be there. We had nothing wrong with living in Parshall.” Many seniors adore their rural communities as much as Ursula, but since their clinics are closing too, they are left with the same difficult decision.

Seniors citizens are not the only victims of the current rural healthcare system. In rural areas, spending a few hours driving for a yearly check-up is not too much of a burden. But when someone sustains an injury that requires long-term recovery, that multi-hour drive to see a healthcare professional becomes arduous.

Andre Hoyte, a healthy man in his forties, lived in a Midwest town that had a population of a couple thousand people. During routine activities, Andre started to notice that his hand would tingle spontaneously throughout the day. As weeks passed, the tingling became more apparent and his physical ability started to deteriorate. After several doctor appointments two hours away from where he lived, Andre was diagnosed with a herniated disk, an injury that would require surgery.

His neurosurgeon, who was educated at a prestigious medical school and practiced in the Northeastern United States for many years, told him that it would take at least three months to recover from the operation, and he might never regain his same function due to permanent damage to the spinal cord. The surgery was performed successfully, but then Andre had to begin the real challenge: physical therapy. The physician prescribed various exercises for Andre’s recovery and told him that he would send the prescription to his local physical therapist. Unbeknown to the urban neurosurgeon, the majority of towns the size of Andre’s no longer had physical therapists. So three times a week for twelve weeks, Andre had to be driven by his wife for two hours to complete physical therapy. This was equivalent to countless sick days, over seventy hours of driving, and five hundred dollars worth of fuel; unfortunately, many urban health professionals like Andre’s surgeon do not realize the sacrifices their patients make to obtain adequate healthcare.

The Shaws, Andre and his wife, and millions of other rural Americans experience the inadequacy of rural healthcare regularly. Although the population of rural America as a whole is decreasing, the population of people who require regular healthcare, the elderly, remains consistent. But, why are healthcare centers closing their doors? According to Dr. Leonard Cohen, a former family practitioner in rural Virginia, when his clinic was forced to shut down, “it [was] not because of a shortage of patients.”4 Instead, Cohen said that the primary reason his clinic was forced to close was a scarcity of medical workers.

Formerly Ursula and Boyd Shaw’s local clinic, this abandoned building is now one of many in Parshall. Source: Myles Odermann.

Upon completion of their education, many healthcare professionals like doctors, nurses, and physical therapists prefer to live and work in an urban-setting due; there, they receive higher wages and can access an abundance of resources. Hilda Heady, former president of the National Rural Health Association, explained in the Vail Daily News, “Rural communities frequently suffer from a shortage of physicians because many doctors feel they cannot sustain a viable practice in a rural setting.”2 So, with hesitations about the rural lifestyle and uncertainties about sustainability of rural clinics, most medical workers decide to follow the safe route and work in urban or suburban places.

Physicians like Stephanie Brown, however, find work in rural communities is more rewarding than in cities. Brown says that in rural clinics, the doctor-patient relationship is more intimate because of the small-community feel.2 The same atmosphere that Ursula and Boyd now long for is the one that Andre traveled seventy hours on the road to feel when he returned home. Many of the physicians in these rural areas attended their state’s public medical school, known for their rural medicine programs—these train doctors in the hope that they will stay and practice medicine in their state. Even though many universities are trying to produce doctors and other medical workers for their region, the shortage of health professionals is still apparent.

Some say that the future of rural medicine lies in telemedicine—where patients can come to a clinic to have a videoconference with their doctor—however, how can someone visually perform a physical examination? They lack any sort of touch to inspect the ears, nose, abdomen, and all other parts of the body. Nothing can replace a doctor’s hands; by forcing rural areas to rely solely on this technology, these residents receive second-rate medical care. But, there is another option. Instead of subjecting rural citizens to mediocre medical care, healthcare professionals can move to small communities, providing access to quality healthcare, a service so foundational to a strong community. If more providers moved to rural places, residents would welcome them with open arms, rejoicing that they can remain in their small-town communities.

Myles Odermann is a sophomore in Saybrook College from Parshall, North Dakota with an anticipated major in Environmental Studies. He can be contacted at myles.odermann@yale.edu.